SPINE Volume 37, Number 22S, pp S31–S39

©2012, Lippincott Williams & Wilkins

ADJACENT SEGMENT PATHOLOGY: GENERAL TOPICS

A Systematic Review of Definitions

and Classification Systems of Adjacent
Segment Pathology
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Paul Kraemer, MD,* Michael G. Fehlings, MD, PhD, FRCSC,† Robin Hashimoto, PhD,‡ Michael J. Lee, MD,§
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Paul A. Anderson, MD,¶ Jens R. Chapman, MD, Annie Raich, MPH,‡ and Daniel C. Norvell, PhD‡

patients with degeneration at the adjacent segment. The ways in

Study Design. Systematic review.
which terms related to adjacent segment “degeneration” or “disease”
Objective. To undertake a systematic review to determine how
are defined in the peer-reviewed literature are highly variable.
“adjacent segment degeneration,” “adjacent segment disease,” or
Conclusion. On the basis of the systematic review presented in
clinical pathological processes that serve as surrogates for adjacent
this article, no formal classification system for either cervical or
segment pathology are classified and defined in the peer-reviewed
thoracolumbar adjacent segment disorders currently exists.
literature.
Consensus Statement
Summary of Background Data. Adjacent segment degeneration
No recommendations regarding the use of current classification of
and adjacent segment disease are terms referring to degenerative
degeneration at any segments can be made based on the available
changes known to occur after reconstructive spine surgery, most
literature. A new comprehensive definition for adjacent segment
commonly at an immediately adjacent functional spinal unit. These
pathology (ASP, the now preferred terminology) has been proposed
can include disc degeneration, instability, spinal stenosis, facet
in this Focus Issue, which reflects the diverse pathology observed at
degeneration, and deformity. The true incidence and clinical impact
functional spinal units adjacent to previous spinal reconstruction and
of degenerative changes at the adjacent segment is unclear because
balances detailed stratification with clinical utility. A comprehensive
there is lack of a universally accepted classification system that
classification system is being developed through expert opinion and
rigorously addresses clinical and radiological issues.
will require validation as well as peer review.
Methods. A systematic review of the English language literature
Strength of Statement: Strong
was undertaken and articles were classified using the Grades of
Key words: adjacent segment disease, adjacent segment
Recommendation Assessment, Development, and Evaluation criteria.
degeneration, adjacent segment pathology, junctional stenosis,
Results. Seven classification systems of spinal degeneration,
cervical spine, lumbar spine, spine surgery, revision spine surgery,
including degeneration at the adjacent segment, were identified.
disc degeneration, spinal stenosis. Spine 2012;37:S31–S39
None have been evaluated for reliability or validity specific to

From the *Indiana Spine Group, Department of Orthopaedic Surgery, Indiana
University, Carmel, IN; †Division of Neurosurgery and Spine Program,
University of Toronto, Toronto, Ontario, Canada; ‡Spectrum Research,
Inc., Tacoma, WA; §Department of Orthopaedics and Sports Medicine,
University of Washington, Seattle, WA; ¶Department of Orthopaedics and
Rehabilitation, University of Wisconsin, Madison, WI; and Harborview
Medical Center, University of Washington, Department of Orthopaedics and
Sports Medicine, Seattle, WA.
Acknowledgment date: April 30, 2012. First revision date: June 28, 2012.
Second revision date: August 3, 2012. Acceptance date: August 3, 2012.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Supported by AOSpine North America, Inc. Analytic support for this work
was provided by Spectrum Research, Inc., with funding from the AOSpine
North America.
One or more of the author(s) has/have received or will receive benefits for
personal or professional use from a commercial party related directly or
indirectly to the subject of this manuscript: for example, honoraria, gifts,
consultancies, royalties, stocks, stock options, decision-making position.
Address correspondence and reprint requests to Paul Kraemer, MD, Indiana
Spine Group, Department of Orthopaedic Surgery, Indiana University, 13225
N Meridian St, Carmel, IN 46032; E-mail: pkraemer@indianaspinegroup.com
DOI: 10.1097/BRS.0b013e31826d7dd6
Spine
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
“A
djacent segment degeneration,” “adjacent segment
disease,” and “ASD,” are terms commonly used
to describe spinal degenerative pathology, which
coexists in the spine after a previous spinal reconstructive pro-
cedure. In the scientific literature, the umbrella term “ASD”
may be used to refer to adjacent segment degeneration, adja-
cent segment disease, or a number of equally poorly defined
terms such as junctional disease, junctional stenosis, or trans-
fer lesion. “Adjacent” has a variety of interpretations, includ-
ing directly above or below the index level, or elsewhere in
the same spinal region, but is generally not commonly used
to refer to other areas of the spine, such as coexisting lum-
bar and cervical pathology. “Degeneration” is also poorly
defined, and may separately refer to osteophyte formation,
intervertebral disc degeneration, spinal stenosis, segmental
instability, facet arthrosis, or significant structural deformity
including kyphosis and scoliosis. Thus, although “ASD” is a
commonly used term, its definition is imprecise at best.
The rate of spinal fusion, particularly that of “complex”
spinal reconstruction,1–4 has seen a significant increase in the
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 ADJACENT SEGMENT PATHOLOGY: GENERAL TOPICS
decade since intervertebral cages were approved in 1996.
Demographic data from Medicare registries1,4 of lumbar spine
stenosis and fusion surgery support a significant increase, and
the US population continues to age, with 7000 new Medi-
care enrollees per day in 2011,5 the year in which the first
“baby boomers” reached 65 years of age. Recent retrospec-
tive series suggest that both cervical and lumbar reoperation
rates at an adjacent segment are roughly 1 in 36,7 to 1 in 5
to 68 at 10 years. Multilevel fusions, or second or third revi-
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sions, are associated with greater complication rates, surgi-
cal difficulty, and costs to the system.3 Together, these trends
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speak to a substantial increase in adjacent level surgery in
upcoming years. There seems to be an urgent clinical need for
a better understanding of relevant factors contributing to this
increase, both to appropriately treat current pathology and
to limit the development of future pathological processes at
adjacent segments.
Current published literature consists largely of retrospec-
tive single-institution series6,7,9 using revision for any reason
as an endpoint, with no universally applied criteria for revi-
sion. We are unaware of any literature-supported criteria for
revision, and expert opinion varies widely. In addition, spinal
pathology at an adjacent segment may manifest itself as sepa-
rate and distinct degenerative processes, which are themselves
disparate indications for primary or revision surgical inter-
vention.
Our goal is to identify a currently accepted and indepen-
dently validated classification scheme to aid in the diagno-
sis of adjacent segment pathology (ASP); in the absence of
this, it is to assess how the peer-reviewed literature defines
terms related to adjacent segment disease and degeneration.
We hope to identify or develop a robust classification system
that will allow for a more concise and complete understand-
ing of the various degenerative pathologies, which together
encompass “ASP.” With an improved understanding, future
treatment of these disorders can be better directed.
Adjacent segment degeneration and disease must be better
understood to treat them effectively, limit their development
in future patients undergoing primary surgery, and main-
tain access to lumbar spine surgery of all types in the face
of increasing government, media, and payor scrutiny. This
systematic review seeks to summarize the current scientific
landscape.
MATERIALS AND METHODS
The purpose of this systematic review was to examine the fol-
lowing key questions (KQs) to elucidate how the terms “adja-
cent segment degeneration” and “adjacent segment disease”
are defined or diagnosed in the published literature:
1. To identify and describe formal systems used to evalu-
ate or diagnose symptomatic or asymptomatic “ASD,”
including those that include or are associated with
patient variables (e.g., pain, neurological dysfunction)
and those that are radiological classifications:
a. Formal classification or diagnostic systems of spinal de-
generative changes adjacent to a previous fusion that
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A Systematic Review of Definitions and Classification
Systems of ASP • Kraemer et al
were developed specifically for the purpose of evaluating
or diagnosing “ASD.”
b. Formal classification or diagnostic systems of disc degen-
eration that are used as a surrogate for functional spinal
unit degeneration next to a fusion.
2. To determine whether the reliability and validity of these
existing systems have been evaluated in previously fused
patients.
3. To summarize the methods used in the studies included in
this focus issue to diagnose “adjacent segment degenera-
tion” or “adjacent segment disease” (including specific
disease processes that serve as surrogates for pathology
at an adjacent segment).
Electronic Literature Search
Systematic searches were conducted for literature pub-
lished through February 2012. Details of the PubMed
searches can be found in the Web appendix (see Supple-
mental Tables 1–3, Supplemental Digital Content 1, avail-
able at http://links.lww.com/BRS/A697).
We first sought to identify formal diagnostic or classifica-
tion systems of “ASD,” that is, those that were developed by
a structured process specifically for the purpose of evaluat-
ing or diagnosing spinal degeneration at an adjacent segment
(KQ 1a). To do this, we conducted a search in PubMed using
key words related to adjacent segment disease or degenera-
tion and combined them with terms related to classification
or diagnostic systems. The articles identified from this search
were included for full-text review if they clearly indicated
in the title or abstract that a classification or grading sys-
tem related to adjacent segment degeneration or disease was
proposed; full-text articles were then reviewed to determine
whether such a system had been developed. Finally, any classi-
fication systems identified from KQ 3 were included in KQ 1a.
We next sought to identify severity measures of disc degen-
eration that are used in definitions of “ASD” in the published
literature (KQ 1b). This uses disc degeneration as a surrogate
measure of ASP, realizing that ASP encompasses a full spec-
trum of disorders. To do this, we utilized the list of degenera-
tive severity measures included in the AOSpine publication
Spine Classifications and Severity Measures.10 A PubMed
search was conducted that combined terms for each severity
measure with terms related to adjacent segments. The articles
identified from this search were included for full-text review if
they clearly indicated in the title or abstract that adjacent seg-
ment degeneration or disease was evaluated; full-text articles
were then reviewed to determine whether the severity mea-
sure of interest was used in the study’s definition of adjacent
segment degeneration. As for KQ 1a, any additional classifi-
cation systems of disc degeneration identified in KQ 3 were
added to the results for KQ 1b.
For KQ 2, we determined whether the severity measures
that were identified as being used in published definitions of
ASD had been tested for predictive validity and/or reliability
in previous fusion patients. A PubMed search was conducted
that combined terms related to each severity measure with
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 ADJACENT SEGMENT PATHOLOGY: GENERAL TOPICS A Systematic Review of Definitions and Classification
Systems of ASP • Kraemer et al

TABLE 1. Patient, Diagnostic Criteria, Outcomes Table for Key Questions 1 and 2
Inclusion Exclusion
Patient Adults ≥18 yrs <18 years
History of spinal pathology, including any of the following: degenerative disease (including disc Cancer,
degeneration, facet degeneration, herniated nucleus pulposus, stenosis, or instability), trauma, deformity, infection
fracture, axial spine pain, radiculopathy, cauda equina syndrome, or neurological dysfunction
Previous fusion or arthroplasty at the index level
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Diagnostic Clinical or radiographical classification or diagnostic systems of symptomatic or asymptomatic ASD

criteria
Clinical or radiographical classification or diagnostic systems of disc degeneration
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Outcomes Components of classification or diagnostic system

Intra- and interobserver reliability
Validity
Definitions used by clinical studies reported in this issue of Spine evaluating symptomatic or asymptomatic
ASD
Study Original article describing classification or diagnostic system Case reports
design
Reliability studies Reviews
Validity studies
Clinical studies reported in this issue of Spine evaluating symptomatic or asymptomatic ASD (including
comparative studies and case series)
ASD indicates adjacent segment disease.

those related to reliability or validity. Articles that clearly indi-
cated in the title or abstract that validity or reliability evalu-
ated in patients with ASD were included for full-text review;
full-text articles were then reviewed to determine whether
the predictive validity or reliability of the severity measure of
interest was evaluated in patients with ASD. For all searches,
we limited our results to humans and to articles published
in the English language and included studies of adjacent seg-
ment degeneration or disease of adult patients with a history
of spinal pathology (including various types of degenerative
disease, trauma, deformity, fracture, axial spine pain, radicu-
lopathy, cauda equina syndrome, or neurological dysfunction)
as described in Table 1. Articles were excluded if patients were
younger than 18 years of age or being treated for cancer or an
infection. Other exclusions included case reports or reviews.
Full texts of potential articles meeting the inclusion criteria by
both methods were reviewed by 2 independent investigators
(RH, AR) to obtain the final collection of included studies
(Figure 1).
For KQ 3, we compiled the definitions of adjacent segment
disease or degeneration (or related pathologies at the adjacent
segment) as reported by all studies included in the other sys-
tematic reviews from this focus issue.

RESULTS

KQ 1a: Formal Classification or Diagnostic

Systems of ASD
Our PubMed search did not yield any formal comprehen-
sive classification or diagnostic systems of either cervical or
thoracolumbar or clinically symptomatic ASD. However, we
did identify 2 ASD classification systems, both cervical, from
the studies included in KQ 3: the radiographical grading of
degenerative changes at adjacent levels severity system by
Figure 1. Flowchart showing results of literature search. KQ indicates Hilibrand et al,7 and Park et al’s11 adjacent level ossification
key question. severity grading system.
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 ADJACENT SEGMENT PATHOLOGY: GENERAL TOPICS A Systematic Review of Definitions and Classification
Systems of ASP • Kraemer et al

TABLE 2. Radiographical Grading of Degenerative Changes at Adjacent Levels by Hilibrand et al 7

Computed Tomography or
Grade Disease Plain Radiography Magnetic Resonance Imaging Myelography, or Both
1 None Normal Normal Normal
2 Mild Narrowing of disc space, no Signal change in intervertebral disc Normal
posterior osteophytes
3 Moderate <50% of normal disc height, Herniated nucleus pulposus without Herniated nucleus pulposus; no nerve-root
posterior osteophytes neural compression cutoff or spinal cord compression
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4 Severe Same as for grade 3 Spinal cord compression with or Nerve-root cutoff with or without spinal
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without nerve-root compression cord compression

Hilibrand et al 7 created the radiographical grading sys-
tem of degenerative changes at adjacent levels. This system
was originally developed as part of a retrospective study that
examined the progression of symptomatic ASD after ante-
rior cervical arthrodesis for degenerative spondylosis and
radiculopathy or myelopathy. The grading system allowed
the authors to qualitatively grade the severity of disc degen-
eration at the adjacent level based on evidence from radio-
graphs, magnetic resonance imaging, and computed tomogra-
phy. Grades were based on evidence of disc space narrowing
and/or osteophyte development on plain radiographs; signal
changes in the disc space; and/or disc herniation with or with-
out nerve root compression on magnetic resonance imaging,
computed tomography, or myelography. Grades ranged from
grade 1 (no disease) to 4 (severe disease) (Table 2).
Park et al’s11 classification system of adjacent-level ossifica-
tion was first described as part of a retrospective cohort study.
Patients who had achieved solid fusion after cervical arthrodesis
were evaluated for ossification at both disc spaces adjacent to
the index level using the proposed grading system. Radiograph-
ical evidence of ossification was based on plain radiographs,
and graded for severity on a 4-point scale that ranged from
grade 0 (no ossification) to 3 (complete bridging) (Table 3).
KQ 1b: Formal Classification or Diagnostic Systems of
Disc Degeneration Used to Diagnose or Define ASP
Next, we sought to identify severity measures of disc degen-
eration that are being used in the published scientific literature
TABLE 3. Adjacent Level Ossification Severity
Grading System by Park et al 11
Grade/Severity of
Ossification Radiographical Evidence
Grade 0 (none) No ossification
Grade 1 (mild) Ossification extending across <50% of
adjacent disc space
Grade 2 (moderate) Ossification extending across >50% of
adjacent disc space
Grade 3 (severe) Ossification completely bridging adjacent
disc space
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to define or diagnose ASD. To this end, we conducted a
PubMed search to identify studies that used any of the fol-
lowing 24 degenerative severity measures (as obtained from
the AOSpine book Spine Classifications and Severity Mea-
sures (chapters 5.4.1 and 5.4.2)10 to define or diagnose adja-
cent segment disease or degeneration: Casey myelopathy dis-
ability index; Cooper Scale; Harsh Scale; Herdman European
Myelopathy Score; Hukuda Japanese Orthopedic Association
(JOA) scale; Muhle cervical spondylotic myelopathy classifi-
cation scale; Nurick Scale; Yukawa classification of increased
signal intensity; Adams Stages of disc degeneration; Carra-
gee lumbar disc herniation classification; Ghiselli University
of California Los Angeles (UCLA) grading system for inter-
vertebral space degeneration; Kellgren and Lawrence osteo-
arthritis severity grade; Kettler cervical spine radiographical
grading system; Kirkaldy-Willis degenerative cascade of spine
disease; Lane osteoarthritis severity grade; Mirza Harborview
disc disease severity score; Modic changes; Pathria facet joint
disease severity grade; Pfirrmann magenetic resonance clas-
sification of lumbar intervertebral disc degeneration; Thalgott
classification of lumbar degenerative disc disease; Thompson
intervertebral disc severity grading system; Weiner radio-
graphical scoring system for osteoarthritis of the lumbar
spine; Weishaupt lumbar facet joint disease severity grade;
and Wilke lumbar spine radiographical grading system.
From this search, we identified 4 studies that used the
UCLA grading system, 3 that utilized the JOA scale, 1 that
employed the Kellgren and Lawrence system, 2 that used
Modic changes, and 1 that utilized Weiner radiographical
scoring system. No studies were identified that used any of
the other 19 degenerative severity measures listed earlier. Fur-
thermore, we did not identify any additional severity mea-
sures of disc degeneration that were used to define ASD by
the studies included in this focus issue (as described in KQ
3 (see Supplemental Table 5). All of the severity measures of
disc degeneration that were identified from KQ 3 overlapped
with those listed earlier: ASD was defined using the Kellgren
and Lawrence osteoarthritis severity grade by 1 study, the
Weiner radiographical scoring system for osteoarthritis of the
lumbar spine by 4 studies, and the Ghiselli UCLA grading
system for intervertebral space degeneration by 2 studies; the
Park ossification grading system was used by 5 studies; and
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Figure 2. Number of studies identified us-
ing classification or severity measures to
define or diagnose adjacent segment de-
generation (ASD) or symptomatic ASD.
No studies were identified that used any
of the remaining 19 degenerative severity
measures (as listed in the text) to define or
diagnose ASD.
the Hilibrand criteria was employed by 4 studies. All of these
severity measures from KQ 1b were lumbar, although the
search was not restricted to lumbar disease. The total number
of studies identified from KQs 1a and 3 that employed each of
these severity measures are summarized in Figure 2.
In summary, for KQ 1, we have identified the following
severity measures used to define or diagnose adjacent segment
disease or degeneration in the published literature: 1 sever-
ity measure of cervical ASD (Hilibrand), 1 severity measure
of cervical adjacent segment heterotopic ossification (Park),
and 5 severity measures of lumbar disc degeneration (UCLA,
Weiner, JOA, Kellgren/Lawrence, and Modic changes).
KQ 2: Predictive Validity and Reliability
of Classification or Severity Measures
Used to Diagnose ASP
We conducted a literature search to determine whether any of
the identified classification systems or severity measures used
in the literature to diagnose ASD have been tested for predic-
tive validity or reliability in previous fusion patients. No stud-
ies evaluating the predictive validity or reliability of any of the
following severity measures were identified: radiographical
grading system of degenerative changes at adjacent levels by
Hilibrand et al7; classification system of adjacent-level ossi-
fication by Park; JOA scale; Modic changes; UCLA grading
system; or Weiner radiographical scoring system.
KQ 3: Definitions of Adjacent Segment Disease or
Degeneration Used in the Studies Included in the
Systematic Reviews of This Focus Issue
The purpose of this KQ was to provide a snapshot of how
studies in the peer-reviewed literature define adjacent segment
disease or degeneration. To do this, we included the defini-
tions in all 94 of the primary studies included in this focus
issue. Of these 94 studies, 67 reported definitions for adjacent
segment disease or degeneration. The definitions are compiled
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A Systematic Review of Definitions and Classification
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in Supplemental Table 5 in the web appendix (Supplemen-
tal Digital Content 1, available at http://links.lww.com/BRS/
A697), and are organized by the topics in this issue.
From these multifaceted definitions, we identified common
individual components being used to define ASD, and have
organized them into the 4 components considered important
in severity scoring10: anatomical, biomechanical, clinical, and
degree of severity components.
Criteria that fulfill the anatomical component indicate
which anatomical structures are affected by the disease. We
determined that of the 67 studies included in this focus issue
that defined adjacent segment disease or degeneration, 67%
included anatomical criteria (Figure 3). The specific criteria
that were included and the frequency with which they were
reported are listed in Figure 4. The most commonly utilized
anatomical criteria included osteophytes (42% of studies),
disc-space narrowing or loss of disc height (37% of studies),
stenosis (19% of studies), “degenerative changes” (10% of
studies), and disc herniation (10% of studies). The remaining
criteria were reported by less than 10% of the 67 studies.
Criteria that meet the biomechanical component assess the
stability of the spine or spinal segments. Of the 67 studies
reporting definitions of adjacent segment disease or degenera-
tion, 46% employed at least 1 biomechanical component in
the definition (Figure 3). Details on the specific criteria and
the frequency with which they were used may be found in
Figure 5. The most commonly used biomechanical compo-
nents included listhesis (15% of studies), instability (12% of
studies), and an increase in the proximal junctional kyphosis
sagittal Cobb angle (10% of studies).
The clinical component refers to criteria that indicate the
patient’s clinical status and includes symptoms and functional
outcome measures (e.g., JOA). A total of 33% of the 67 stud-
ies included at least 1 clinical component in the definition of
ASD. In this case, all definitions would pertain to symptom-
atic ASD, or adjacent segment disease. The individual clinical
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criteria are listed in Figure 6, and include new radiculopathy
(15%), new back pain (10%), and new myelopathy (9% of
studies) that were referable to the adjacent segment. Another
commonly required clinical component of the symptomatic
ASD definition was second surgery, which was reported by
9% of the studies.
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A Systematic Review of Definitions and Classification
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Figure 3. Anatomical, biomechanical, clinical, or de-
gree of severity component reported (percentage of the
67 studies from focus issue with adjacent segment dis-
ease definition).
Finally, the severity measure component refers to crite-
ria that provide a distinction between levels or grades of
disease severity; this component was the least commonly
reported as it was included in definitions of ASP by only
25% of the studies (Figure 3). The individual severity mea-
sure and frequency of their use is documented in Figure 7.
Figure 4. Anatomical components report-
ed (percentage of the 67 studies from focus
issue with adjacent segment disease defini-
tion).
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Figure 5. Biomechanical components reported (percent-
age of the 67 studies from focus issue with adjacent seg-
ment disease definition). PJK indicates proximal junc-
tional kyphosis.
No individual severity measure was used by 10% or more
of studies.
DISCUSSION
After a thorough review of the literature, relatively little light
is shed on ASP processes. Few classification systems have been
proposed specifically relating to adjacent segment disease
or adjacent segment degeneration. The cervical systems are
unique to the cervical spine, particularly the degree of adjacent
level ossification, more prevalent in anterior approaches com-
mon in the cervical spine. The lumbar systems are not unique
to adjacent segment degnerative changes, but relate to disc
deneration in general. Disc degneration is a common compo-
nent of ASP, and sometimes serves as a surrogate for “ASD” as
Figure 6. Clinical components reported (percent-
age of the 67 studies from focus issue with ad-
jacent segment disease definition). *Referable to
the adjacent segment. NR indicates not reported.
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A Systematic Review of Definitions and Classification
Systems of ASP • Kraemer et al
it is currently used, but is by no means synonomous with the
full spectrum of adjacent level pathologies encountered.
We determined in KQ 1a and 1b that minimal useful
“ASD” classification systems currently exist, particularly for
thoracolumbar disease, where the specific component disc
degeneration was used as a surrogate. In KQ 2, we determined
that none of the classifications used in defining ASD had been
tested for reliability or validity in this patient population.
In KQ 3, it arises from observation that no currently accepted
definition of “ASD” or “adjacent segment degeneration” (or
other terms mentioned earlier) exists; and therefore many defi-
nitions comprised of many anatomical, biomechanical, and
clinical observations have been compiled. Similar to the redun-
dancy and nonspecific overlapping terms of the International
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Figure 7. Degree of severity components

reported (percentage of the 67 studies from
focus issue with adjacent segment disease
definition). JOA indicates Japanese Ortho-
paedic Association; UCLA,

Classification of Diseases, ninth edition, nomenclature of

‰ In the peer-reviewed literature, terms including “ad-
many spinal diseases, this has lead to the inability to identify
jacent segment disease” or “adjacent segment de-
any given pathological process uniquely. This is most evident generation” seem to consist of multiple pathological
in Figure 4 of the appendix, where 4 of the top 5 anatomical components observed in many studies, using many
descriptors are near-synonyms for degenerative changes of the overlapping terms, but including intervertebral disc de-
disc. The overlapping terms “adjacent segment degeneration,” generation, segmental instability, spinal stenosis, facet
adjacent segment “disease,” “junctional stenosis,” “transfer arthrosis, and structural deformity including kyphosis.
lesion,” and others further obscure the picture. This is because
multiple terms are used for the same undefined collection of
Acknowledgments
nonspecific nomenclature referring to unvalidated clinical and/
The authors thank Ms. Nancy Holmes, RN, and Chi Lam, MS,
or radiographical findings.
for their administrative assistance. The author P.K. contributed
toward primary manuscript authorship, design and methodol-
CONSENSUS STATEMENT
ogy, editing of Methods and Results section, managing consen-
No recommendations regarding the use of current classifica-
sus definitions, and managing deadlines and submission pro-
tion of degeneration at any segments can be made based on
cess; M.G.F.: design and methodology, interpretation of results,
the basis of available literature. A new comprehensive defini-
and manuscript writing and editing; R.H.: design and method-
tion for adjacent segment pathology (ASP, the now preferred
ology, literature searches, assessing studies for inclusion/exclu-
terminology) has been proposed in this focus issue, which
sion, analyzing data, and writing methods and results; A.R.:
reflects the diverse pathology observed at functional spinal
literature searches, assessing studies for inclusion/exclusion,
units adjacent to previous spinal reconstruction and balances
analyzing data, and compiling and verifying adjacent segment
detailed stratification with clinical utility. A comprehensive
definitions; D.N.: design and methodology; and M.L., P.A.A.,
classification system is being developed through expert opin-
and J.R.C.: editorial contributions and expert opinion.
ion and will require validation as well as peer review.
Strength of Statement: Strong Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are pro-
vided in the HTML and PDF versions of this article on the
journal’s Web site (www. spinejournal.org).
➢ Key Points
References
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A Systematic Review of Definitions and Classification
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